1、子宫内膜癌 endometrial carcinoma 广西医科大学妇产科教研室 范江涛,overview,3rd commonest cancer in women in China The disease normally occurs in postmenopausal women Median age 61 years old 2-5% diagnosed 40 year old 75% diagnosed at Stage ,确切病因尚不清，可能与下列因素有关： 1.雌激素依赖型(Estrogen-dependent)（I型）：,一、发病相关因素,The estrogen-depen
2、dent disease, unopposed estrogen stimulation is considered the major risk factor for endometrial cancer(EC).,Risk factors of estrogen-dependent EC,Chronic Estrogen Exposure: oral contraceptives without progestins, estrogen-secreting tumors, and the long-term use of tamoxifen; Obesity: 2-5 fold great
3、er risk. This is likely due to the fact that fat cells produce estrogen; Diabetes Mellitus and Hypertension; anovulation associated: PCOS, anovulatory AUB Menopausal unopposed estrogen replacement: increase the risk for EC by 4-8 times,characters of type I EC,younger well-differentiated PR and ER po
4、sitive better prognosis,2.非雌激素依赖型（II型）： 与雌激素无明显关系，与基因突变有关（P53，P16等）。多见于年老体瘦女性，病理类型是少见的子宫内膜浆液性腺癌、透明细胞癌、黏液腺癌等。恶性程度高、分化差、雌孕激素受体多阴性。,1巨 检(gross observation)： (1)弥漫型： 侵及大部分内膜或全部内膜，呈菜花状、灰白 色，豆腐渣样。少有肌层侵犯。 (2)局灶型： 局限内膜的一个区域，多见于宫底或宫角部。 呈小菜花或结节状，易侵犯肌层。,Pathology,弥漫型,局灶型,Pathology,Histology,(1)Endometrial aden
5、ocarcinoma(内膜样腺癌)：about 8090%,the most common carcinomas found in the endometrium,Histology,(2)Adenocarcinoma with squamous differentiation,(3)Adenosquamous carcinoma,(4)Uterine Papillary Serous Carcinoma, UPSC,(5)Clear cell adenocarcinoma,uncommon, 1-9%, highly aggressive, found in advanced stages,
6、 early spread,rare, 4%, older postmenopausal women, poor pronosis, early spread,(6)Mucinous adenocarcinoma,direct extension to adjacent sites lymphatic spread hematogenous spread transtubal passage of exfoliated cells,Patterns of Spread,以直接蔓延和淋巴转移为主,晚期有血行转移。 1.直接蔓延： 宫角输卵管、卵巢盆腹膜 肌层浆膜输卵管、卵巢盆腹膜子宫直肠窝大网膜
7、。 宫颈阴道,Patterns of Spread,2.淋巴转移 为主要转移途径,癌累及宫颈、深肌层或癌组织分化不良时，容易淋巴转移。与部位有关。 宫底阔韧带淋巴网骨盆漏斗韧带卵巢腹主动脉 旁淋巴结 宫角圆韧带腹股沟淋巴结 子宫下段、宫颈管宫旁髂内、外髂总淋巴结 子宫后壁宫骶韧带直肠淋巴结； 前壁膀胱阴道前壁,Patterns of Spread,3. Hematogenous spread This occurs late, with the most common site being the lungs. Other potential sites include the liver,
8、brian, or osseous(骨的) metastases.,Patterns of Spread,期 癌局限在子宫体 I a期 侵犯肌层1/2 I b期 侵犯肌层 1/2,四、手术病理分期(FIGO, 2009),Ib,Ia,II 期 肿瘤侵犯宫颈间质，但无宫体外蔓延,II期, 期 肿瘤局部和（或）区域扩散 a期 肿瘤累及浆膜和(或)附件 b期 阴道和（或）宫旁转移 c期 盆腔和(或)腹主动脉旁淋巴结转移 c1 盆腔淋巴结阳性 c2 腹主动脉旁淋巴结转移伴或不伴盆腔淋巴结阳性,IIIa,IIIb,IIIc,期：肿瘤侵及膀胱和（或）直肠粘膜，和（或）远处 转移 a期 肿瘤侵犯膀胱和（或）
9、直肠粘膜 b期 远处转移， 包括腹腔内和（或）腹股沟淋巴结 转移,Clinical findings,signs （1）The uterus may be soft and enlarged slightly in the early stages. （2）Signs of advanced cases include pelvic pressure or pain, increased urinary frequency, conspitation, the presence of a palpable mass, or ascites.,Clinical findings,1. histo
10、ry and clinical findings 2. tranvaginal Ultrasound or MR 3. fractional curettage 4. hysteroscopy 5. endometrial aspiration biopsy 6. serum CA125,Diagnosis,病史及临床表现,对于绝经后阴道出血、绝经过渡期月经紊乱，均应排除子宫内膜癌。对于有子宫内膜癌高危相关因素者应高度警惕。 （1）肥胖、不育、绝经延迟 （2）长期应用雌激素、tamoxifen或雌激素增高病史 （3）有乳腺癌、内膜癌家族史者,影像学检查,阴道超声: 异常阴道出血时初筛，子宫大小
11、、宫腔形态、内膜厚度、宫腔赘生物有无、肌层浸润与否. MRI：治疗前评估，对于肌层浸润深度和宫颈间质浸润判断较准确；CT协助判断有无子宫外转移,诊断性刮宫（diagnostic curettage）： 最常用最可靠的确诊方法。 先用小刮匙刮颈管，再进宫腔搔刮内膜，刮出物分瓶 标记送检。,分段诊刮,能直视宫腔及宫颈管内病灶并可定位活检，对较小病灶更 有价值。,宫 腔 镜 检 查,(1)子宫内膜抽吸活检(endometrial aspiration biopsy)：子宫内膜活检的专用吸管和刮匙，国内尚未开展。 (2)血清CA125 ：有宫外转移者升高，监测手段。,其 他 诊 断 方 法,1、功能失
12、调性子宫出血：主要表现为月经紊乱，如经量增多、经期延长、经间出血或不规则流血，诊刮活检可明确 。 2、老年性阴道炎：主要表现为血性白带。抗炎后复查，必要时 诊刮。 3、子宫粘膜下肌瘤或息肉：多表现为月经增多及经期延长。 4、内生型宫颈癌、子宫肉瘤及原发性输卵管癌：表现为阴道排液、不规则阴道流血和下腹疼痛。诊刮和影像学帮助鉴别。,鉴 别 诊 断(differential diagnosis),Treatment,Operation, radiotherapy, chemiotherapy, and hormonal therapy can be used in the management of
13、 EC, according to the age, health status and the organs involved of the patients. Surgical procedure should be the first choice for the early stage of EC. 高危因素：非子宫内膜样腺癌或低分化腺癌，深肌层浸润、脉管间隙受侵、肿瘤体积大、宫颈转移、淋巴转移和子宫外转移。,surgery,The standard treatment for EC is and remains a total abdominal hysterectomy and b
14、ilateral salpingo-oophorectomy. The operation commences with an adequate abdominal incision, allowing for a thorough abdominal exploration as well as possible lymphadenectomy. A pelvic washing is obtained using saline, or if ascites is present, this is aspirated and sent for cytology. Any suspicious
15、 or obvious areas of extrauterine disease are biopsied. surgical staging procedure laparoscopic procedure for EC is considered to be the standard option at present time Omentumorectomy should be performed for some rare histologies and the cases with the ovary involved.,Lymphadenectomy,myometrial inv
16、asion more than 1/2 myometrial layer cervical extension extrauterine spread serous, clear cell, or undifferetiated histologies any enlarged lymph nodes Grade 3 endometrial adenocarcinoma more than 50% of the uterine cavity is involved,Surgery for stage II of EC,radical hysterectomy and bilateral sal
17、pingo-oophorectomy and pelvic lymhpadenectomy and paraaortic lympha node sampling,放疗,单纯放疗：有手术禁忌证或无法手术切除的晚期患者。 放疗联合手术及化疗：术后放疗是I期高危和II期子宫内膜癌最主要的术后辅助治疗。降低局部复发和改善无瘤生存期。,化疗,晚期或复发子宫内膜癌综合治疗措施之一，也可用于术后有复发高危因素患者的治疗以期减少盆腔外转移。 子宫浆液性癌术后均予以化疗，方案同卵巢上皮性癌。,孕激素治疗,主要用于晚期或复发癌，极早期要求保留生育功能的年轻患者。 孕激素以高效、大剂量、长期为宜，12周以上评估效
18、果。孕激素受体阳性者有效率80%。 常用药物：醋酸甲羟孕酮200-400mg/d；己酸孕酮500mg,每周两次。 注意药物副作用。,随访,术后2-3年内重要。 随访内容：病史、盆腔检查、阴道细胞学涂片、胸部x-ray、CA125等，必要时CT、MRI检查。 方法：术后2-3年内，每3个月1次，3年后每6个月1次,5年后每年1次。,1.重视绝经后妇女阴道出血和绝经过渡期妇女月经紊乱。 2.注意高危因素及高危病人。 3.掌握雌激素使用指征。 4.加强对林奇综合征妇女的监测，甚至预防性子宫和双附件切除。,预 防,小结 1、熟悉子宫内膜癌的病理 2、熟悉子宫内膜癌的手术-病理分期 3、掌握子宫内膜癌的临床表现、诊断和防治措施 思考题 1、子宫内膜癌的临床表现有哪些？如何诊断？ 2、子宫内膜癌的治疗原则是什么？,小结与思考题,Thank you for your attendance!,
